Preventing rural workforce by design.

With 2.7 trillion dollars in annual health spending(1), America has no excuse for designs that have failed for decades with regard to rural health workforce development. Rural workforce failure can best be understood as the inevitable result of failure by design. Designs for revenue are insufficient to support the rural clinician workforce that would resolve deficits. The designs of health professional training are not specific to rural health needs. Those aware of rural health delivery problems such as the National Rural Health Association have noted 'the overriding healthcare problem in rural America is lack of access to a provider. Being insured makes no difference if you cannot find a doctor in your area'. A second concern noted is eliminating 'long-standing payment inequities for rural providers'(2). National designers have failed to grasp what is important for rural health care. Basic services provided by generalists and physicians remaining in core specialties such as general surgery are most important and are most neglected by payment and training designs. Generalists delivering primary care are half of the rural workforce(3). Training must produce the generalists, general surgeons, and other general specialties that are over 75% of rural workforce needs in 2013(4). Designs that shape more new specialties, more in each specialty, lowest proportions entering primary care, and departures from primary care only a few years after graduation are prevention of rural workforce by design.